25 January 2012

Less Invasive Surgery Procedures

 First appeared on Chron.com
Dr. Sandra Hurtado moved her right hand, ever so slightly, and a kidney appeared on the screen.

"Keep coming," surgical robotics instructor Armando Garcia urged. "Keep coming ... Now, go right above it with your left hand."

Hurtado, an ob-gyn, has performed laparoscopic surgeries since leaving medical school more than 20 years ago. But last week, she was at Memorial Hermann Hospital's surgical training lab to gain skills in a movement that has sharply reduced the demand for traditional surgical procedures.

Despite resistance from some peers, Hurtado and other midcareer surgeons are scrambling to keep pace with the growth in less-invasive surgical techniques, allowing them to satisfy patients' demands for smaller scars and quicker recoveries.

Young surgeons learn the procedures during training, but Dr. Daniel Albo, chief of surgical oncology at Baylor College of Medicine, said some older surgeons still resist.

"There's an ego that gets in the way of a surgeon saying, 'I need to get back and retrain,' " Albo said. "Laparoscopic surgery requires a completely different skill set.

"Think of it as grandpa versus the grandson playing video games," he said. "For the grandson, it is very intuitive. For the grandpa, it's an aggravation."

Cost factor unclear

There aren't definitive statistics for how many of the 27 million surgical procedures performed in the United States every year are done with minimally invasive techniques or how much money that saves.

Some people question the conventional wisdom that the new techniques save money, since the up-front costs can be high. But that hasn't slowed the rush toward the new procedures.

The revolution started in France in 1987, when a gynecologist used a video monitor and specialized instruments to remove a patient's gallbladder through small incisions, rather than the traditional hip-to-hip cut across the abdomen.

Similar procedures had been done before, but that procedure in Lyons, France, is considered the true beginning of minimally invasive surgery. Now, it's the standard way to remove a gallbladder.

Colorectal surgeries, at the other extreme, are still done almost exclusively via a large incision, Albo said.

Minimally invasive surgery includes a variety of techniques: Cardiologists use stents as an alternative to chest-cracking coronary bypasses. Surgeons use endoscopes, inserted through the mouth or another body opening, for some procedures. Laparoscopic procedures use special tools inserted through one or more small incisions.

A tiny camera is slipped inside the body to display the view on a video screen, since the surgeon can't see the internal organs directly.

Challenge for veterans

The techniques require a shift in mindset, said Dr. Shawn Tsuda, chief of the division of minimally invasive and bariatric surgery at the University of Nevada Medical School.

"You're looking at a two-dimensional screen instead of the patient's body and tissues," he said. "For the young generation, maybe they play video games or punch in texts on their tiny phones. They're good at it.

"For more experienced surgeons, it can be a real challenge."

From bariatric surgery to breast augmentation surgery, robot-assisted surgeries are the next frontier.

The video display is three-dimensional, and Hurtado said the tools offer more dexterity than those used in traditional laparoscopic surgery.

She and her Obstetrical & Gynecological Associates colleagues at the Woman's Hospital of Texas already perform mostly minimally invasive procedures, but some patients still require more extensive open surgery, she said.

Last week she was learning to use robot-assisted tools, which she said will reduce the need for that.

Patients like the smaller incisions and faster recovery. Erik Wilson, a surgeon and faculty member at the University of Texas Medical School at Houston, said patients always ask for minimally invasive procedures.

"That's where everything is going because that's what everyone wants," said Wilson, a founding member of the Clinical Robotic Surgery Association. "I don't open people up for anything unless they're critically ill and you just don't have any time."

Financial edge?

There is less agreement on the financial advantages. Initial costs increase to pay for the new surgical tools, Tsuda said.

Robot-assisted surgery has especially high startup costs; Peter Herrera, director of surgical innovation at Memorial Hermann, said each station and its accompanying tools cost $1.5 million or more.

But most patients leave the hospital sooner than those who undergo traditional surgery.

They also have fewer complications and return to work more quickly, all of which can reduce costs over time.

"If you look at global health care costs, the cost of not only the procedure itself, but of complications, the cost of managing complications, recovery times, return to work times, then laparoscopic surgery reduces the cost of care," Albo said.

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